SOAP Note for Gynecological Exam

A strong SOAP note for a gynecological exam must detail the Subjective history, including the last menstrual period (LMP), contraceptive use, and obstetric history. The Objective section requires a systematic breakdown of the physical exam, specifically noting the external genitalia, speculum exam (cervix and vaginal walls), and bimanual exam (uterine size, position, and adnexal tenderness). The Assessment should synthesize these findings into a differential or confirmed diagnosis, while the Plan outlines screenings, prescriptions, or follow-up imaging.

Using Aduvera eliminates the need to manually transcribe these repetitive but critical exam findings from memory. Instead of starting with a blank page, the AI scribe captures the conversation and the clinician's dictated findings during the encounter, organizing them into the SOAP format. This allows the provider to focus on the physical examination while ensuring that no critical detail—such as a specific cervical finding or a patient's reported symptom—is omitted from the final EHR entry.